Patient Compliance With Patient Compliance With Medical Advice Medical Advice

Patient compliance (patient adherence) :Patient compliance (patient adherence) :

The extent to which the patient adheres to The extent to which the patient adheres to medical advicemedical advice

Patient compliance includes:Patient compliance includes:

Taking medicationsTaking medications Keeping appointmentsKeeping appointments Undertaking recommended preventive Undertaking recommended preventive

measuresmeasures Changing behavioral patternsChanging behavioral patterns

Non compliance can be caused by:Non compliance can be caused by:

Failure to understand instructionsFailure to understand instructions Non comprehensionNon comprehension Volitional non complianceVolitional non compliance

How big a problem is medication non How big a problem is medication non compliance?compliance?

Up to 60% of all medication prescribed is Up to 60% of all medication prescribed is taken incorrectly or not taken at all!taken incorrectly or not taken at all!

Medication noncompliance Medication noncompliance includes:includes:

Not filling a prescriptionNot filling a prescription Over medicationOver medication Taking wrong medicationTaking wrong medication Taking right medication in a wrong timeTaking right medication in a wrong time Forgetting to take medicationForgetting to take medication Deliberately under dosing or not taking medicationDeliberately under dosing or not taking medication

This can happen because of not giving This can happen because of not giving explanations to the patient.explanations to the patient.

Overall rates of noncompliance:Overall rates of noncompliance:

90% of elderly patients make some medication 90% of elderly patients make some medication errors.errors.

35% of elderly patients make potentially serious 35% of elderly patients make potentially serious errors. errors.

50% of all long term medications are abandoned 50% of all long term medications are abandoned in the first year.in the first year.

75% of chronic care patients prescribed drugs 75% of chronic care patients prescribed drugs either stop taking their medication at some point either stop taking their medication at some point or don’t take them as directed.or don’t take them as directed.

Only 75% of patients who understand and agree Only 75% of patients who understand and agree with treatment are compliant.with treatment are compliant.

How much does How much does noncompliance causenoncompliance cause??

An estimated 125,000 lives could be saved An estimated 125,000 lives could be saved annually with better medication compliance.annually with better medication compliance.

The total annual cost of noncompliance is 100 The total annual cost of noncompliance is 100 billion $$ (45 billion in the health care industry).billion $$ (45 billion in the health care industry).

Noncompliance leads to 3.5 million hospital Noncompliance leads to 3.5 million hospital admissions annually, or 11% of all admissions.admissions annually, or 11% of all admissions.

In the elderly 40% of all admissions are due to In the elderly 40% of all admissions are due to medication problems.medication problems.

Noncompliance is the greatest cause of re-Noncompliance is the greatest cause of re-admissions to hospitals.admissions to hospitals.

Noncompliance causes admission of Noncompliance causes admission of 380,000 patients to nursing homes (23% 380,000 patients to nursing homes (23% of all admissions) and is the key factors in of all admissions) and is the key factors in admissions.admissions.

Noncompliance in medication taking can be Noncompliance in medication taking can be classified as:classified as:

Errors of omissionErrors of omission Errors of commission Errors of commission Dosage errorsDosage errors

Scheduling errorsScheduling errors

Patient’s noncompliance is important from Patient’s noncompliance is important from at least 4 perceptions:at least 4 perceptions:

Individual patient care.Individual patient care. Public health efforts.Public health efforts. Interpretation of the medical literature.Interpretation of the medical literature. Economic consequences.Economic consequences.

When patients do not take their medications When patients do not take their medications correctly:correctly:

They may not get better.They may not get better. Can get sicker / worsen the disease.Can get sicker / worsen the disease. Can have a relapse.Can have a relapse.

Health Effects:Health Effects:

Increase morbidityIncrease morbidity Treatment failureTreatment failure Exacerbation of diseaseExacerbation of disease Increases frequent physician visitsIncreases frequent physician visits Increases hospitalizationIncreases hospitalization DeathDeath

Economic EffectsEconomic Effects

Increases absenteeism Increases absenteeism Lost productivity at workLost productivity at work Lost revenues to pharmaciesLost revenues to pharmacies Lost revenues to pharmaceutical manufacturersLost revenues to pharmaceutical manufacturers

Dimensions of compliance : some things we Dimensions of compliance : some things we think we knowthink we know

- Initial noncompliance or defaulting- Initial noncompliance or defaulting 2% - 20%, possibly as high as 50%2% - 20%, possibly as high as 50% Average 8.7%Average 8.7%

- Refill compliance or persistence- Refill compliance or persistence Decreases over timeDecreases over time

- Not all noncompliance is improper medication use- Not all noncompliance is improper medication use Rational noncomplianceRational noncompliance

Importance of Compliance :Importance of Compliance :

Prevalence of noncompliancePrevalence of noncompliance

Rates vary from less than 10% to over 90% Rates vary from less than 10% to over 90% depending on the setting.depending on the setting.

Cross sectional studies of patients taking Cross sectional studies of patients taking medications chronically show 20 – 70 % of medications chronically show 20 – 70 % of noncompliancenoncompliance

Example:Example: among newly diagnosed hypertensive, 50% fail to follow among newly diagnosed hypertensive, 50% fail to follow

throw with referred advice.throw with referred advice.

Over 50% who began treatment drop out by 1 year.Over 50% who began treatment drop out by 1 year.

Reasons: believes, side effects, cannot take pills, patient did Reasons: believes, side effects, cannot take pills, patient did not trust the doctor.not trust the doctor.

Higher rates for preventive care.Higher rates for preventive care. Noncompliance increase with duration of Noncompliance increase with duration of

therapytherapy Highest for regimens that requires Highest for regimens that requires

significant behavioral change (e.g. significant behavioral change (e.g. smoking cessation, weight loss)smoking cessation, weight loss)

Missed appointments are more common Missed appointments are more common for provider-initiated than patient-for provider-initiated than patient-initiated visits.initiated visits.

Asymptomatic patients are more likely to Asymptomatic patients are more likely to miss appointments.miss appointments.

Lack of comprehension of a regimen Lack of comprehension of a regimen (20% to 70% non compliance).(20% to 70% non compliance).

Measurements of ComplianceMeasurements of Compliance

Methods of measurementsMethods of measurementsApproaches to assessing compliance behavior in Approaches to assessing compliance behavior in

patients patients

AskingAsking Medication countingMedication counting AssayAssay SupervisionSupervision

Often necessary to use more than one method to Often necessary to use more than one method to arrive at a reasonably valid estimate of arrive at a reasonably valid estimate of compliance in the individual patient.compliance in the individual patient.

Ability to predict complianceAbility to predict compliance

Sometimes no better than would be expected by chanceSometimes no better than would be expected by chance

Methods of measurement:Methods of measurement:

1. Asking: 1. Asking:

simplest and most practical method of assessing compliance simplest and most practical method of assessing compliance behavior.behavior.

Self-reports of noncompliance are valid, but often result in Self-reports of noncompliance are valid, but often result in underestimation of the degree of noncompliance.underestimation of the degree of noncompliance.

Only 40%-80% of patients admit their noncompliance . Only 40%-80% of patients admit their noncompliance .

Self-reported compliance over estimate true compliance rates.Self-reported compliance over estimate true compliance rates.

Manner of asking influences the accuracy of patient response. Manner of asking influences the accuracy of patient response.

2. Medication Counting: 2. Medication Counting:

More objective but it has problems:More objective but it has problems:

OverestimationOverestimation underestimationunderestimation

3. Assays3. Assays

Limitations:Limitations:

Assays can be expensive.Assays can be expensive.

Multiple measurements are required over extended period of Multiple measurements are required over extended period of time. time.

Patient may take medicine immediately before the collection of Patient may take medicine immediately before the collection of specimen but not at other time.specimen but not at other time.

Differences in drug absorption, distribution, metabolism, Differences in drug absorption, distribution, metabolism, excretion.excretion.

(whether a low level represents noncompliance or inadequate dosage (whether a low level represents noncompliance or inadequate dosage in patient???).in patient???).

Collection of specimens has to be timed correctly, at Collection of specimens has to be timed correctly, at appropriate times, absence of any drugs in the specimen appropriate times, absence of any drugs in the specimen suggests noncompliance.suggests noncompliance.

Assays are not available for many medications.Assays are not available for many medications.

Patient ConsiderationsPatient Considerations

Factors believed to affect compliance:Factors believed to affect compliance:

Patient knowledge.Patient knowledge. Prior compliance behaviorPrior compliance behavior Ability to integrate into daily life / Complexity of the particular Ability to integrate into daily life / Complexity of the particular

drug regimen.drug regimen. Health beliefs and perceptions of possible benefits of treatment Health beliefs and perceptions of possible benefits of treatment

(self efficiency) (self efficiency) Social support (including practitioner relationships)Social support (including practitioner relationships)

Health Beliefs:Health Beliefs:

How serious is my diseaseHow serious is my disease What are the sequences of being careless in treating the What are the sequences of being careless in treating the

diseasedisease Self efficiencySelf efficiency

Factors which NOT believed to be associated with Factors which NOT believed to be associated with compliance:compliance:

Age, race, gender, income or education.Age, race, gender, income or education. Patient intelligence.Patient intelligence. Actual seriousness of the disease or the efficiency of the Actual seriousness of the disease or the efficiency of the

treatment.treatment.

Patients in Higher Risk:Patients in Higher Risk:

1. Asymptomatic conditions1. Asymptomatic conditions Hypertension.Hypertension.

2. Chronic conditions2. Chronic conditions Hypertension, arthritis, diabetes.Hypertension, arthritis, diabetes.

3. Cognitive impairment 3. Cognitive impairment Dementia, Alzheimer.Dementia, Alzheimer.

4. Complex regimens4. Complex regimens Poly pharmacy.Poly pharmacy.

5. Multiple daily dosing5. Multiple daily dosing

6. Patient perceptions6. Patient perceptions Effectiveness, side effects, cost.Effectiveness, side effects, cost.

7. Poor communication 7. Poor communication Patient practitioner rapport Patient practitioner rapport

8. Psychiatric illness8. Psychiatric illness Less likely to comply.Less likely to comply.

Factors associated with complianceFactors associated with compliance

Environmental factorsEnvironmental factors

Good social support, assistance of family.Good social support, assistance of family.

Depending on cultural norm about gender.Depending on cultural norm about gender.

Social class.Social class.

Previous experiences of similar disease among Previous experiences of similar disease among relatives or friends can affect one’s compliance.relatives or friends can affect one’s compliance.

Appointment keeping is positively correlated Appointment keeping is positively correlated with appointment scheduling system with appointment scheduling system that:that:

Reduce waiting time.Reduce waiting time.

Give individual rather than block appointment.Give individual rather than block appointment.

Minimize the time between scheduling and the Minimize the time between scheduling and the actual appointment date.actual appointment date.

Make referrals to specific doctors rather than to Make referrals to specific doctors rather than to clinics.clinics.

Good Luck Good Luck